Fillable Ssa-3376-bk Function Report - Child Age 1 to 3rd Birthday

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Ssa-3376-bk Function Report - Child Age 1 to 3rd Birthday

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Form SSA-3376-BK (10-2017) UF
Discontinue Prior Editions
Social Security Administration
Function Report - Child Age 1 to 3rd Birthday
Filling Out The Function Report
IF YOU NEED HELP COMPLETING ANY PART OF THIS FORM, CONTACT YOUR
SOCIAL SECURITY OFFICE. WE WILL HELP YOU.
The information that you give us on this form will be used by the office that makes the
disability decision on the child's claim. You can help them by completing as much of the
form as you can.
•
Print or type.
•
Do not ask a doctor or hospital to complete this form.
•
Be sure to explain your answer if an explanation is requested or needed.
•
If more space is needed to answer any of the questions, please use the
"REMARKS" section and show the number of the question being answered.
The information we ask for on this form tells us how you think the child's illnesses or injuries
affect the way he or she does many of his or her usual activities.
PLEASE REMOVE THIS SHEET BEFORE
RETURNING THE COMPLETED FORM.
Continued on the Reverse
Page 1 of 9
OMB No. 0960-0542
- This information collection meets the requirements of
44 U.S.C. §3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 20 minutes to read the instructions, gather the facts, and
answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. The office is listed under U.S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send
comments on our time estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.
Privacy Act Statement
Collection and Use of Personal Information
Paperwork Reduction Act Statement
Form SSA-3376-BK (10-2017) UF
Sections 205(a), 223(d), and 1631(e)(1), of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide on behalf of the minor child to
determine his or her benefit eligibility.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may prevent us from making an accurate and timely decision on the claim.
We rarely use the information for any purpose other than for making a decision regarding
entitlements to benefits. However, we may use it for the administration and integrity of our programs.
We may also disclose the information to another person or to another agency in accordance with
approved routine uses, including but not limited to the following:
1. To enable a third party or an agency to assist us in establishing rights to our benefits and
coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g. to
the Government Accountability Office and Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at
the Federal, State, and local level; and,
4. To facilitate statistical research, audit, and investigatory activities necessary to assure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to private
entities under contract with us).
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies. We
use the information from these programs to establish or verify a person’s eligibility for federally
funded and administered benefit programs and for repayment of incorrect payment’s or delinquent
debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act System of Records
Notices entitled, Claims Folders Systems, 60-0089. Additional information about this and other
system of records notices and our programs are available on-line at www.socialsecurity.gov or at
your local Social Security office.
Page 2 of 9
Form SSA-3376-BK (10-2017) UF
Discontinue Prior Editions
Social Security Administration
FUNCTION REPORT - CHILD
AGE 1 TO 3rd BIRTHDAY
Page 3 of 9
OMB No. 0960-0542
SECTION 1 - IDENTIFYING INFORMATION
1.
A. Print NAME OF CHILD:
FIRST MIDDLE LAST
B. Child's SOCIAL SECURITY NUMBER:
C. Child's DATE OF BIRTH:
Month/Day/Year
D. PERSON COMPLETING FORM
NAME:
RELATIONSHIP TO CHILD:
DATE FORM COMPLETED:
Month/Day/Year
DAYTIME TELEPHONE NUMBER (including Area Code) :
MAILING ADDRESS (Number and Street, Apt. No. (if any), P.O. Box, or Rural Route) :
CITY STATE ZIP CODE
If " yes," please mark every statement below that is generally true
about the child:
SECTION 2 - FUNCTION DETAILS
2. A. Does the child have
problems seeing?
YES (Continue)
NO (Go to 2.B.)
If " yes," please mark every statement below that is generally true
about the child:
Child uses glasses or contact lenses. If the child has
problems seeing even with glasses or contact lenses,
please explain:
Child cannot be fitted for glasses or contact lenses. Explain:
Child has other seeing problems. If so, please describe:
B. Does the child have
problems hearing?
YES (Continue)
NO (Go to 2.C.)
Child uses hearing aid(s). If the child has problems hearing
even with a hearing aid(s) OR has trouble using a hearing
aid, please explain:
Child cannot be fitted for hearing aid(s)
Child has other hearing problems. If so, please describe:
Child uses American Sign Language
Child reads lips
Form SSA-3376-BK (10-2017) UF
Page 4 of 9
C. Is the child totally unable
to talk?
Form SSA-3376-BK (10-2017) UF
2.
YES (Go to 2.D.)
NO (Continue)
Does the child have problems talking
(for example, saying simple words)?
Yes (answer questions below)
No (continue to question 2.D.)
If " yes ," please mark every statement below that is generally
true about the child:
Says simple words like "he," "bottle," "doggy"
Uses two-word phrases, such as "mommy go" or "push
toy"
Uses short sentences of 4 or more words, such as "Can I
go out?"
Has a vocabulary of at least 50 words
For each of the two statements below, mark the block that best
describes the child, and then describe any other speech problems:
The child's speech can be understood by people who know
the child well:
Most of the time, or
Some of the time, or
Hardly ever
The child's speech can be understood by people who don't
know the child well:
Most of the time, or
Some of the time, or
Hardly ever
If the child has other problems talking, please explain:
Page 5 of 9
If " yes," or " not sure," please tell us what the child does or can do
by checking "yes" or "no" for the following:
Form SSA-3376-BK (10-2017) UF
2. D. Does the child have
difficulty understanding
and learning?
YES (Continue)
NO (Go to 2.E.)
NOT SURE
(Continue)
Waves "bye-bye"
Plays pat-a-cake
Uses one or more words (can be made-up
words) to ask for toys, food, or people
Follows most simple, one-step directions,
such as "come here" or "give it to me"
Knows and can point to parts of face or
body such as eye or hand when asked
Plays "pretend" with dolls or stuffed
animals
Uses own name or "I" or "me" to refer to
self
Listens at least 5 minutes to stories being
read
Follows two-step directions, such as "find
your shoe and bring it to me"
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's ability to
understand and learn:
Page 6 of 9
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Form SSA-3376-BK (10-2017) UF
2. E. Are the child's physical
abilities limited?
YES (Continue)
NO (Go to 2.F.)
NOT SURE
(Continue)
If " yes," or " not sure," please tell us what the child does or can
do by checking "yes" or "no" for each of the following. Check "yes"
if it is something the child used to do but doesn't do any more just
because he or she is older. For example, if the child used to stand
with help, and can now stand without help, check "yes" for both.
Crawl
Stand with help
Stand without help
Walk holding on to someone or something
Walk without holding on
Climb onto furniture
Throw a ball or other object
Dance or jump up and down
Walk up and down steps by self
Run, but may fall down sometimes
Run without falling
Stack small blocks 2 high
Stack small blocks 4 high
Stack small blocks 6 high
Push and pull small toys
Scribble with a crayon or pencil
Hold crayon or pencil with thumb and
fingers, not fist
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's physical abilities:
Page 7 of 9
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes
No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If " yes," or " not sure," please tell us what the child does or can
do by checking "yes" or "no" for each of the following:
If " yes," or " not sure," please tell us what the child does or can
do by checking "yes" or "no" for each of the following:
F. Does the child's
impairment(s) affect his
or her behavior with
other people?
Form SSA-3376-BK (10-2017) UF
2.
YES (Continue)
NO (Go to 2.G.)
NOT SURE
(Continue)
Yes No Is affectionate towards parents
Yes No Says "no" a lot
Yes No Plays next to other children but not with them
Yes No
Plays "catch" or other simple games with
other children
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's behavior around
other people:
G. Is the child's ability to
help take care of his or
her personal needs
limited?
YES (Continue)
NO (Go to 2.H.)
NOT SURE
(Continue)
Yes No Cooperates in getting dressed
Yes No Cooperates in brushing teeth
Yes No Drinks from a cup or glass without help
Yes No Feeds self with spoon
Yes No Can undress by self
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's ability to take
care of his or her personal needs:
H. Please tell us anything else about the child that you think we should know.
Page 8 of 9
Form SSA-3376-BK (10-2017) UF
SECTION 3 - REMARKS
Page 9 of 9
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Ssa-3376-bk Function Report - Child Age 1 to 3rd Birthday

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Completed 9 February 2020

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